EFFECT OF NURSE-LED TRAINING ON SELF-MANAGEMENT OF DIABETES AMONG DIABETIC PATIENTS ATTENDING MEDICAL OUT-PATIENT CLINIC IN GENERAL HOSPITAL ODAN LAGOS STATE

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Diabetes mellitus (DM) is a metabolic disease in which glucose level in the blood is high over extended periods (World Health Organization, 2014). DM results when the pancreas is unable to produce insulin or cell of the body is not responding to insulin produced  (Shoback, 2011). In 2013 alone 4.6 million people died of DM (Aschner, Beck-Nielsen, Bennett, Boulton, & Colagiuri, 2013). Low and middle-income countries of the world is being affected by DM, there are more than 77 % morbidity and 88 % mortality (International Diabetes Federation, 2013). Type 2 diabetes mellitus (T2DM) is the commonest form of DM and it account for 90 % of disease (Aschner et al., 2013).

13.2% is the prevalence rate of DM with registered 4,600 people (International Diabetes Federation, 2014). Estimate of the World Health Organization (WHO) states that DM prevalence among adults in 2014 was 9%, a prediction of at least 350 million people with T2DM by 2030 (WHO, 2015). In accordance with a national survey carried out, the prevalence of diabetes mellitus in Nigeria increased from 2.2% to 5.0% by 2013 estimates of the International Diabetes Federation (IDF). Complications of diabetes are common at the time of presentation in Nigeria: neuropathy 56%, erectile dysfunction 36%, nephropathy 9%, and retinopathy 7% (Chinenye & Ofoegbu, 2013). This is partly because diabetes is a progressive illness with an initial asymptomatic phase associated with on-going tissue damage and decline in pancreatic beta cell mass and function.

Ali, Barke, Bullard, Gregg, and Imperatore, (2012) reported that glycemic control at the suboptimal level likely cost diabetic patients increased care requirement, complications and related health care costs. Improper glycemic control has a link with an increased risk of visual impairment, kidney failure and cardiovascular disease (Balkau, Borch-Johnsen, Colagiuri, Lee, Shaw &Wong, 2011). The possible reasons for poor glycemic control includes poor adherence and awareness, manpower insufficiency, time constraint, lack of appropriate guidelines on diabetic education for health practitioners and diabetic patients (Amade, Gudina, Ram, & Tesfamichael, 2011).

Because of lack of awareness, patients with DM suffer from its complications (Gul, 2010). The way to self-management includes testing the blood glucose, adequate diet, regular examination of the foot and eye, all this have shown to reduce complications from DM (Aschner et al., 2013; Biswas, Ferrari, Islam, Islam, Lechner &Niessen, et al., 2015).Therefore, proper blood glucose control among Diabetes Mellitus patients prevents short and long-term complications and reduce cost and long hospital stay.

The aim of self-management of DM is to ensure that the blood glucose level is at a normal range and to reduce the risk of complications. There are seven self-care behavior people having DM must ensure to keep their glucose level normal: they include eating healthy, physically active, self-monitoring of glucose content, compliance with medication, risk-reduction behaviors, good problem-solving and healthy coping skill (American Association of Diabetes Educators, 2010). This measures are useful for physicians managing diabetic patients and it has impacted positively on glycemic control, complication reductions and improvement in quality of life (American Diabetes Association, 2009). Self-management goals and its implementation are written in collaboration with the diabetic patient and health care professionals, it promotes patient self-management, decrease the prevalence of DM and its complications (Ahola & Groop, 2013).

Haidet, Naik, Rodriguez and Teal (2011), also emphasized the importance of patient education for better outcomes of self-management of diabetes, stated that patient education is necessary because it promote high quality diabetic care. Diabetic education programmes stress the importance of patients comprehending the practical approach to self-manage their disease condition. Knowledge and understanding are important in helping patients towards better self-management of diabetes mellitus.

 Education help people having DM initiate good self-management and coping skill. Continuous DM education help people having the disease care for themselves.(American Diabetes Association, 2014).There is good report when intervention is long term, it includes follow-up and patients care is individualized. Intervention which promotes behavioral changes improves clinical outcome (Haidet, Naik, Rodriguez &Teal, 2011).Anderson and Funnell (2013), said that self-management education is a process of facilitating knowledge, skill and ability, is an important component of an effective diabetic management. Self-Management place patients at center of care, empowering patients to make decision that will improve clinical outcome.

1.2 Statement of the Problem

Diabetes Mellitus has significantly contributed to the reduction of life expectancy by 15 years and have increased heart disease incidence by four time (IDF, 2014; WHO, 2014). In Nigeria, diabetes mellitus contributes to medical morbidity and mortality (Chinenye, Ogbera, & Onyekwere, 2013). Patients having diabetes stay long on medical wards and pay high bills with various complications such as stroke, adult-onset blindness, lower extremity amputation from foot gangrene, heart/kidney failure and premature death (Fasanmade, Nwaiwu & Olayemi, 2015; Isezuo, Ohwovoriole,  & Sabir, 2013). An estimated 3.4 million persons died of high glucose level in 2004 & 2010 according to WHO (Fact sheets, 2013).

According to International Diabetes Federation, (2010), the prevalence of DM in Nigeria varies from 0.65% in rural Mangu to 11% in urban Lagos state. World Health Organization, (2014), suggest that Nigeria have the highest number of people having diabetes. In Nigeria, up to 73% of diabetic patients do not practice self-monitoring of blood glucose (Chinenye, Uchenna, & Unachukwu, 2010; Chinenye, et al., 2013). A study done in Malaysia, (Azmi, Barakatun-Nisak, & Firouzi, 2015) show 72 % of patients with poor glycemic control and in Ethiopia  (Abebe, Alemu, Berhane, Mesfin, & Worku, 2015) show two third of patients with poor control.

American Association of clinical Endocrinologist, (2010) report that 1 in 3 patients having T2DM is controlled while one and half of patients comply with medication.  It was obvious from this and other surveys that the status of glycemic control and other targets such as lipid, glycated hemoglobin (HbA1c), blood pressure levels and adequate education were below expectations (Chinenye, et al., 2013; IDF, 2012).Therefore, the need for a study on effect of nurse-led training on self-management of diabetes amongst diabetic patients attending medical outpatient clinic in General Hospital Odan, Lagos.

1.3 Objective of the Study

The main objective of the study is to evaluate the effect of nurse-led training on self-management of diabetes amongst diabetic patients. The specific objectives are to

1. assess diabetic patient’s knowledge of self-management of diabetes pre/post-intervention;
2. determine diabetic patient’s practice of self-care activities pre/post-intervention;
3. implement the nurse-led training on self-management of diabetes;
4. determine the effect of nurse-led training on diabetic patient’s knowledge of self-management of diabetes pre/post-intervention and
5. determine the effect of nurse-led training on diabetic patient’s practice of self-care activities pre/post-intervention.

1.4 Research Questions

The following research questions were answered:

1. What is diabetic patient’s knowledge regarding self-management of diabetes pre/post intervention?
2. What is diabetic patient’s practice of self-care activities pre/post intervention?

1.5 Hypotheses

The following hypotheses were tested at 0.05 level of significance.

HO₁     There is significant effect in nurse-led training on diabetic patient’s                   knowledge regarding self-management of diabetes between pre/post-intervention   respondents.

HO₂     There is significant effect in nurse-led training on diabetic patient’s self-care practice between pre/post-intervention respondents.

1.6 Scope of the Study         

The researcher studied the effect of nurse-led training on self-management of diabetes mellitus among diabetic patients. The study was limited to diabetic patients who attend the medical out-patient’s clinic of general hospital odan Lagos.

1.7 Significance of the Study

Patients may benefit from this study as the outcome may help improve clinical performance and decision making. Also, training program may improve knowledge of diabetes mellitus. It may influence patient’s satisfaction, cost of care, prevalence, morbidity and mortality rate. It may improve blood glucose level, prevent acute and chronic complication, enhance quality of life, maintain cost effectiveness and reduce diabetes burden globally. They may also benefit as the outcome may improve behavioral changes which includes blood glucose self-monitoring, adequate diet, adherence to medication, eye examination and foot care. The hospital management may benefit from the study as it may positively influence the utilization of hospital resources for better purpose.

1.8 Operational Definition of Terms

Operational definition was utilized to define the following terms in the study:

1. Effects: the extent to which a planned training program on diabetes mellitus achieves the desired outcome as measured by gain in knowledge and control.

2. Nurse-led training programme: teaching on diabetes mellitus, prevention, treatment, and management designed, organized and given by a nurse to improve patient’s knowledge and control.

3. Diabetes Mellitus (DM) – A metabolic disease in which the body cannot properly control     the amount of glucose in the blood because it does not have enough insulin.

4. Self-Management– are activities individuals perform on their own throughout life to promote and maintain personal well-being thereby preventing complications that arise from diabetes mellitus.

5. Patients– A person who is receiving nursing care on diabetes mellitus and has medical diagnosis of diabetes mellitus.

6. Outpatient clinic– A patient who receives treatment in a medical facility for the diagnosis   and treatment of diabetes mellitus but is not admitted overnight.

7. General hospital– a state owned hospital that provides secondary healthcare services as well as training health professionals.